Inspection·May 24, 2021

F 0550 and required supervision of one staff with eating. Level of Harm - Minimal harm or potential for actual harm Observation on 05/17/21 at 12:00 P.M. revealed STNA #715 was feeding lunch to Resident #19 with resident seated in bed and STNA standing over resident for the entire meal. Further observation revealed STNA addressed resident as sweetheart, honey, and baby. STNA did not refer to resident by his name. Residents Affected - Few Interview on 05/17/21 at 12:17 P.M. with STNA #715 confirmed she had fed Resident #19 from a standing position and that she referred to resident as sweetheart, honey, and baby instead of his name. Interview on 05/17/21 at 1:58 P.M. with Resident #19 confirmed he preferred that staff be eye level with him when assisting with meals and he preferred to be called by his first name. Review of the facility policy titled Assistance with Meals dated 06/27/18 revealed residents who could not feed themselves would be fed with attention to safety, comfort and dignity to include not standing over residents while assisting them with meals and avoiding the use of labels when referring to residents (i.e. feeder, sweetie, honey, etc.). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 2 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, staff interview, and review of facility policy, the facility failed to notify a residents physician of multiple refusals of insulin. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 60. Findings include: Review of the medical record for Resident #18 revealed an admission date of 12/23/20 with a diagnosis of diabetes mellitus. Review of the Minimum Data Set (MDS) for Resident #18 dated 12/30/20 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.) Review of the monthly physician orders for Resident #18 for April 2021 and May 2021 revealed orders for Lantus insulin to be administered per subcutaneous injection twice daily, 36 units in the morning and 18 units in the evening. Review of the April and May 2021 Medication Administration Records (MAR) revealed the following morning doses (36 units) of insulin were refused by the resident on the following dates: 04/05/21, 04/06/21, 04/19/21, 04/20/21, 04/24/21, 05/03/21, 05/04/21, 05/08/21, 05/09/21, 05/12/21, 05/13/21, 05/17/21, 05/18/21. The evening doses were refused on the following dates: 04/30/21, 05/01/21, 05/06/21, 05/16/21. Review of the nurse progress notes for Resident #18 dated 04/05/21 through 05/20/21 revealed the notes contained no documentation regarding physician notification of the resident's multiple refusals of insulin in April 2021 and May 2021. Interview on 05/20/21 9:52 A.M. with the Director of Nursing (DON) confirmed Resident #18's record contained no documentation regarding physician notification of resident's multiple refusals of insulin in April 2021 and May 2021. Review of the facility policy titled Medication Administration dated 09/2018 revealed if two consecutive doses of a vital medication are withheld or refused, the physician is notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 3 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interview and policy review, the facility failed to maintain confidentiality of medical record information for residents during medication pass. This affected four (#12, #32, #35, and #46) out of 15 residents residing on the hall. Facility census was 60. Residents Affected - Few Findings include: Observation of medication administration pass was conducted on 05/19/21 at 8:10 A.M. with Licensed Practical Nurse (LPN) #510 administer morning medications to Resident #32. LPN #510 stated she had to go to the emergency box to obtain missing medication and when she walked away from medication cart she left Resident #32's medical information up on the computer screen which obtained his name, birth date, admission date, and list of medications. In addition, LPN #510 left a nurses report sheet face up on medication cart which obtained medical information of antibiotic use for Resident #12 and Resident #35 and fall information for Resident #46. Observation was conducted on 05/19/21 at 8:25 A.M. of LPN #510 administer morning medications to Resident #12. Observations revealed when LPN #510 entered Resident #12's room she left report sheet face up on medication cart revealing medical information of antibiotic use for Resident #12 and Resident #35 and fall information for Resident #46. Interview was conducted on 05/19/21 at 8:30 A.M. with LPN #510 and she stated she knew she left her computer screen up when she walked away from medication cart and she also verified that she left her report sheet face up on top of medication cart and stated she knew better. Review of facilities Medication Administration General Guidelines Policy dated September 2018 revealed resident's health information needs to remain private. The pages of the medication administration record containing resident health information must remain closed or covered when not in direct use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 4 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff, resident and hospice personnel interview, review of a police report, review of facility self-reported incidents (SRI's) and facilities policy review, the facility failed to report a possible diversion of residents medications to the Ohio Department of Health. This affected one (#26) out of two residents reviewed for pain. Facility census was 60. Findings include: Review of the medical record for Resident #26 revealed an admission date of 03/19/21 with diagnoses including malignant neoplasm unspecified part of unspecified bronchus or lung, chronic pain syndrome, depressive episodes, and anxiety. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, received opiod medication and was on hospice care. Review of physician orders dated May 2021 revealed Resident #26 was on opiod medication Fentanyl patch and to administer Fentanyl 100 micrograms (mcg) transdermal with Fentanyl 25 mcg patch every 72 hours. Review of nurses notes dated 05/03/21 written by Registered Nurse (RN) #780 revealed she placed two Fentanyl patched to Resident #26's left upper arm this morning at 7:15 A.M. and at approximately 9:30 A.M. the aide on the unit notified the nurse that the resident reported one of his patches was falling off and needed reinforced. When nurse entered the residents room, the 100 mcg Fentanyl patch was completely off of his arm and no longer had any adhesive left on it and RN #780 notified a second nurse (RN #500) to witness that the Fentanyl patch had also been cut diagonally across the right side by a sharp object. RN #780 proceeded to reinforce the patch back onto his left upper arm with a clear opsite dressing. Physician and hospice nurse were notified and will continue to monitor. Review of nurses notes dated 05/03/21 through 05/15/21 revealed no further notes concerning Fentanyl patch. Review of physician notes dated 03/31/21 and 05/17/21 revealed no concerns related to Fentanyl patches. Observation and interview was conducted on 05/18/21 at 9:42 A.M. with Resident #26 and he was laying in bed , two patches was noted to left upper arm, he stated he would like something different then the patches for pain because they are never on his arm. He stated they fall off his arm and sometimes they just fall off and he can't find them. Interview was conducted on 05/19/21 at 10:57 A.M. with RN #780 and she stated she was the nurse for Resident #26 on 05/03/21 and that Resident #26 had stated his Fentanyl patches was not staying on and she thought it was odd because she had just put it on his arm and when she went into his room there was no adhesive at all and the one patch looked like to was cut diagonally. RN #780 stated she did let hospice nurse know and hospice was to notify the physician and no follow up that she is aware of. She verified she did not let the Director of Nursing (DON) or the Administrator know. She stated she did have another nurse (RN #500) look at the patch because she thought it was suspicious that it looked like it had been cut. RN #780 stated this was the only issue she has had with his Fentanyl (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 5 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 patches. Level of Harm - Minimal harm or potential for actual harm Interview was conducted on 05/19/21 at 11:35 A.M. with the DON stated she was not made aware of the incident on 05/03/21 where Resident #26's Fentanyl patch had appeared to be cut or that Resident #26 was having any concerns of Fentanyl patch falling off of his arm. Residents Affected - Few Observation was conducted on 05/19/21 at 11:40 A.M. of Resident #26 and he was sitting up on side of his bed. Resident #26 had no Fentanyl patches in place to his left arm or any other area of his body. He stated he had them on earlier and that they must have fallen off. Interview was conducted on 05/19/21 at 11:40 A.M. with the DON as she was made aware of missing Fentanyl patches to Resident #26 by surveyor. The DON immediately searched his bed and his jacket and no patches were located. Resident #26 could not say what happened to them only that they must have fallen off. Interview was conducted on 05/19/21 at 11:44 A.M. with Licensed Practical Nurse (LPN) #510 revealed she is Resident #26's nurse and that she had no idea his patches were missing and that she was not sure if he had them on his arm this am or not. She stated they were placed on 05/18/21 per order every 72 hours. She stated she never knew to be monitoring for patches to his arm. She stated she usually is Resident #26's nurse and she had no idea of incident on 05/03/21. Interview was conducted on 05/19/21 at 11:57 A.M. with the DON stated they have called the Medical Director and received new orders to discontinue the Fentanyl patches, and order placed for Methadone and he had oxycodone ordered. She stated they called the police, the staff will be drug tested, and that they are doing their investigation. Interview was conducted on 05/20/21 at 9:44 A.M. with the DON stated the facility has started their investigation and that Resident #26's Fentanyl patches had been discontinued and that Resident #26 denied anyone taken it off. She verified they could not find the missing two patches after search of his room, bed, and courtyard due to he smokes and no patches were located. She stated police did come in facility, they have started drug screening and investigation was ongoing from 05/19/21. When asked about the incident charted on 05/03/21, the DON verified they had not done any investigation or interviews from 05/03/21. Interview was conducted on 05/20/21 at 10:34 A.M. with RN #500 and she stated she was working a different hall on 05/03/21 and RN #780 asked her to look at Resident #26's Fentanyl patches due to adhesive was coming off and one patch looked as though it was cut off. She stated it was one of the corners and it appeared to be clipped off. She stated she knew RN #780 notified hospice of the suspicious cut in his Fentanyl patch. Interview was conducted on 05/20/21 at 12:59 P.M. with the DON stated they have started on education to nurses this date on notification to the DON on changes to address the incident that occurred on 05/03/21 with Resident #26's Fentanyl patches. Interview was conducted on 05/24/21 at 6:23 P.M. with Hospice RN #805 revealed she visits with Resident #26 once a week. She stated she never knew his Fentanyl patches were not staying in place and falling off. She stated Resident #26 had not voiced any concerns to her or having any increased pain or discomfort. RN #805 stated she was not made aware of the 05/03/21 incident where it appeared that his Fentanyl patch was cut. She stated the first she has heard anything about his Fentanyl patches (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 6 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 was this week. Level of Harm - Minimal harm or potential for actual harm Review of the police report dated 05/21/21 revealed police responded to facility on 05/19/21 after receiving call from the Administrator regarding two missing Fentanyl patches for Resident #26. The police talked with Resident #26 and he believed his patches just fell off and he had no idea where they are. The Administrator stated Resident #26 has had no visitors in the time frame since the last time Fentanyl patches were seen. Resident #26 denied eating them. Residents Affected - Few Review of facility SRI's revealed the facility did not report an allegation of misappropriation on 05/03/21 regarding Resident #26's Fentanyl patch appearing to be cut. Review of facilities Controlled Medication and Drug Diversion Policy dated 06/01/15 revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping with the facility in accordance with federal, state and other applicable laws and regulations. Report any discrepancies in controlled substances to the DON immediately. Investigation and make every reasonable effort to reconcile reported discrepancies including any missing or lost controlled substances. Review of facilities Abuse, Neglect, and Misappropriation of Property Policy dated 05/08/19 revealed it is the organization's intentions to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property and to assure that all alleged violations of federal and State laws are investigated, and reported immediately to the Administrator, the state agency, and other appropriate State and local agencies in accordance with Federal and State law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 7 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff, resident and hospice personnel interview, review of a police report, review of facility self-reported incidents (SRI's) and facilities policy review, the facility failed to investigate a possible diversion of residents medications. This affected one (#26) out of two residents reviewed for pain. Facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of 03/19/21 with diagnoses including malignant neoplasm unspecified part of unspecified bronchus or lung, chronic pain syndrome, depressive episodes, and anxiety. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, received opiod medication and was on hospice care. Review of physician orders dated May 2021 revealed Resident #26 was on opiod medication Fentanyl patch and to administer Fentanyl 100 micrograms (mcg) transdermal with Fentanyl 25 mcg patch every 72 hours. Review of nurses notes dated 05/03/21 written by Registered Nurse (RN) #780 revealed she placed two Fentanyl patched to Resident #26's left upper arm this morning at 7:15 A.M. and at approximately 9:30 A.M. the aide on the unit notified the nurse that the resident reported one of his patches was falling off and needed reinforced. When nurse entered the residents room, the 100 mcg Fentanyl patch was completely off of his arm and no longer had any adhesive left on it and RN #780 notified a second nurse (RN #500) to witness that the Fentanyl patch had also been cut diagonally across the right side by a sharp object. RN #780 proceeded to reinforce the patch back onto his left upper arm with a clear opsite dressing. Physician and hospice nurse were notified and will continue to monitor. Review of nurses notes dated 05/03/21 through 05/15/21 revealed no further notes concerning Fentanyl patch. Review of physician notes dated 03/31/21 and 05/17/21 revealed no concerns related to Fentanyl patches. Observation and interview was conducted on 05/18/21 at 9:42 A.M. with Resident #26 and he was laying in bed , two patches was noted to left upper arm, he stated he would like something different then the patches for pain because they are never on his arm. He stated they fall off his arm and sometimes they just fall off and he can't find them. Interview was conducted on 05/19/21 at 10:57 A.M. with RN #780 and she stated she was the nurse for Resident #26 on 05/03/21 and that Resident #26 had stated his Fentanyl patches was not staying on and she thought it was odd because she had just put it on his arm and when she went into his room there was no adhesive at all and the one patch looked like to was cut diagonally. RN #780 stated she did let hospice nurse know and hospice was to notify the physician and no follow up that she is aware of. She verified she did not let the Director of Nursing (DON) or the Administrator know. She stated she did have another nurse (RN #500) look at the patch because she thought it was suspicious that it looked like it had been cut. RN #780 stated this was the only issue she has had with his Fentanyl patches. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 8 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview was conducted on 05/19/21 at 11:35 A.M. with the DON stated she was not made aware of the incident on 05/03/21 where Resident #26's Fentanyl patch had appeared to be cut or that Resident #26 was having any concerns of Fentanyl patch falling off of his arm. Observation was conducted on 05/19/21 at 11:40 A.M. of Resident #26 and he was sitting up on side of his bed. Resident #26 had no Fentanyl patches in place to his left arm or any other area of his body. He stated he had them on earlier and that they must have fallen off. Interview was conducted on 05/19/21 at 11:40 A.M. with the DON as she was made aware of missing Fentanyl patches to Resident #26 by surveyor. The DON immediately searched his bed and his jacket and no patches were located. Resident #26 could not say what happened to them only that they must have fallen off. Interview was conducted on 05/19/21 at 11:44 A.M. with Licensed Practical Nurse (LPN) #510 revealed she is Resident #26's nurse and that she had no idea his patches were missing and that she was not sure if he had them on his arm this am or not. She stated they were placed on 05/18/21 per order every 72 hours. She stated she never knew to be monitoring for patches to his arm. She stated she usually is Resident #26's nurse and she had no idea of incident on 05/03/21. Interview was conducted on 05/19/21 at 11:57 A.M. with the DON stated they have called the Medical Director and received new orders to discontinue the Fentanyl patches, and order placed for Methadone and he had oxycodone ordered. She stated they called the police, the staff will be drug tested, and that they are doing their investigation. Interview was conducted on 05/20/21 at 9:44 A.M. with the DON stated the facility has started their investigation and that Resident #26's Fentanyl patches had been discontinued and that Resident #26 denied anyone taken it off. She verified they could not find the missing two patches after search of his room, bed, and courtyard due to he smokes and no patches were located. She stated police did come in facility, they have started drug screening and investigation was ongoing from 05/19/21. When asked about the incident charted on 05/03/21, the DON verified they had not done any investigation or interviews from 05/03/21. Interview was conducted on 05/20/21 at 10:34 A.M. with RN #500 and she stated she was working a different hall on 05/03/21 and RN #780 asked her to look at Resident #26's Fentanyl patches due to adhesive was coming off and one patch looked as though it was cut off. She stated it was one of the corners and it appeared to be clipped off. She stated she knew RN #780 notified hospice of the suspicious cut in his Fentanyl patch. Interview was conducted on 05/20/21 at 12:59 P.M. with the DON stated they have started on education to nurses this date on notification to the DON on changes to address the incident that occurred on 05/03/21 with Resident #26's Fentanyl patches. Interview was conducted on 05/24/21 at 6:23 P.M. with Hospice RN #805 revealed she visits with Resident #26 once a week. She stated she never knew his Fentanyl patches were not staying in place and falling off. She stated Resident #26 had not voiced any concerns to her or having any increased pain or discomfort. RN #805 stated she was not made aware of the 05/03/21 incident where it appeared that his Fentanyl patch was cut. She stated the first she has heard anything about his Fentanyl patches was this week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 9 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of the police report dated 05/21/21 revealed police responded to facility on 05/19/21 after receiving call from the Administrator regarding two missing Fentanyl patches for Resident #26. The police talked with Resident #26 and he believed his patches just fell off and he had no idea where they are. The Administrator stated Resident #26 has had no visitors in the time frame since the last time Fentanyl patches were seen. Resident #26 denied eating them. Residents Affected - Few Review of facility SRI's revealed the facility did not report an allegation of misappropriation on 05/03/21 regarding Resident #26's Fentanyl patch appearing to be cut. Review of facilities Controlled Medication and Drug Diversion Policy dated 06/01/15 revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping with the facility in accordance with federal, state and other applicable laws and regulations. Report any discrepancies in controlled substances to the DON immediately. Investigation and make every reasonable effort to reconcile reported discrepancies including any missing or lost controlled substances. Review of facilities Abuse, Neglect, and Misappropriation of Property Policy dated 05/08/19 revealed it is the organization's intentions to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property and to assure that all alleged violations of federal and State laws are investigated, and reported immediately to the Administrator, the state agency, and other appropriate State and local agencies in accordance with Federal and State law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 10 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI) manual and review of the facilities Centers for Medicare and Medicaid Services (CMS) submission report, the facility failed to timely transmit a Minimum Data Set (MDS) assessment to CMS database. This affected one (#01) out of 20 residents reviewed for MDS coding accuracy and transmission. Facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #01 revealed an admission date of 11/16/20 with diagnoses of diabetes mellitus and chronic obstructive pulmonary disease. Resident #01 was discharged from the facility on 02/07/21. Review of the MDS revealed an admission MDS was completed and submitted on 11/23/21. The discharge MDS dated [DATE] was still in process and was never submitted to CMS database. Interview was conducted on 05/20/21 at 10:21 A.M. with Registered Nurse (RN) #740 and she verified the discharge MDS dated [DATE] was not submitted for Resident #01 and she was not sure why as the MDS was completed but was still marked in their system as being in process. Interview was conducted on 05/20/21 at 10:42 A.M. with RN #740 and she stated she submitted the discharge MDS for Resident #01 and verified it was submitted late past the 14 days of submission requirement after 02/07/21. Review of the MDS 3.0 RAI Manual dated October 2019 revealed discharge MDS assessments must be completed within 14 days after the discharge date and then submitted to data base 14 days after the completion date. Review of facilities CMS submission report dated 05/20/21 revealed Resident #01's discharge MDS was submitted late and that the submission date was more than 14 days after the completion date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 11 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #62 revealed a readmission date of 04/26/21 with diagnoses including but not limited to multiple sclerosis, anxiety, hypertension, and kidney failure. Residents Affected - Few Review of the five day MDS dated [DATE] revealed Resident #62 was cognitively intact and was coded no to having dressings to feet. Review of treatment administration records dated April 2021 and May 2021 revealed an order for a treatment to wash and dry heels with soap and water, pat dry, apply Vaseline and then wrap with kerlix every day was started on 04/30/21 and discontinued on 05/18/21. Observation was conducted on 05/17/21 of Resident #62 and she had kerlix wrap to both feet. Interview was conducted on 05/20/21 at 9:30 A.M. with Registered Nurse (RN) #740 verified Resident #62's five day MDS dated [DATE] was inaccurately coded for dressings to feet and that Resident #62 did have daily dressings to feet and should have been coded on the five day MDS. Based on record review, observation, resident and staff interview, the facility failed to ensure resident assessment were accurate regarding dental status and regarding application of dressings to the feet. This affected two (#59 and #62) of 24 residents sampled. The census was 60. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 07/31/20 with a diagnosis of chronic kidney disease. Review of the care plan for Resident #59 dated 07/31/20 revealed resident exhibited dental/mouth problems related to having her own teeth. Interventions included dental consult as needed. Review of the comprehensive Minimum Data Set (MDS) for Resident #59 dated 08/07/20 revealed resident was cognitively intact and was not coded as edentulous or having dental concerns. Review of oral assessment for Resident #59 dated 08/01/20 revealed the resident was coded as none of the above for the following list of potential dental concerns: broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose), no natural teeth or tooth fragment(s) (edentulous), abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn), obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. Observation of Resident #59 on 05/17/21 2:11 P.M. revealed the resident was edentulous and had an upper denture but no lower denture. Interview on 05/17/21 at 2:11 P.M. with Resident #59 confirmed the resident was edentulous upon admission and had an upper denture but was missing her lower denture upon admission. Interview on 05/19/21 4:43 P.M. with Registered Nurse (RN) #740 confirmed the MDS for Resident #59 dated 08/07/20 was inaccurate regarding resident's dental status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 12 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely complete a Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (#37) out of two residents reviewed for PASARR. The facility census was 60. Findings include: Review of the medical record for Resident #37 revealed an admission date of 03/30/21 with diagnoses including diabetes mellitus, cystitis, dyspahgia, and pulmonary embolism. Diagnosis of schizoaffective disorder was added on 04/01/21. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive deficits, had schizophrenia diagnosis, and PASARR question of is resident considered by state level two PASARR process to have serious mental illness or related condition was answered no. Review of the medical record for Resident #37 revealed the record contained no documentation for any PASARR being completed. Review of PASARR provided by facility dated 05/19/21 revealed diagnosis of schizophrenia and PASARR determination date of 05/19/21. Review of hospital exemption dated 03/25/21 revealed it was sent to a different facility and was coded no to having diagnosis of schizophrenia. Interview was conducted on 05/19/21 at 2:28 P.M. with Social Service Director (SSD) #770 verified Resident #37's PASARR was not done until 05/19/21. SSD #770 stated when she looked there was none and that her exemption had even went to another facility upon admission and she had to call department of aging to obtain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 13 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and resident and staff interview, the facility failed to arrange for audiology services for residents. This affected one (#22) of 24 residents sampled. The census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/17/20 with a diagnosis of pyonephrosis. Review of the Minimum Data Set (MDS) for Resident #22 dated 11/30/20 revealed resident was cognitively impaired, required extensive assistance of one staff with activities of daily living (ADL's), and had impaired hearing. Review of the Care Area Assessment (CAA) Worksheet for Resident #22 dated 11/20/20 revealed resident had a hearing deficit and might miss parts of conversations and did not wear hearing aids. Review of the care plan for Resident #22 dated 11/20/20 revealed the resident had impaired communication as evidenced by a hearing deficit, and not wearing hearing aids. Interventions included the following: report changes in communication status to physician, use the following techniques to enhance communication, allow adequate time, do not rush or supply words, speak clearly and slowly, repeat as necessary, stand where resident can see your face and mouth, minimize or eliminate environmental distractions (radio, TV,etc.), use questions that can be answered yes or no, use simple, brief consistent wording/cues as needed (PRN) and anticipate/meet needs per physical/non-verbal indicators of discomfort/distress and follow up as indicated. Review of the physician orders for Resident #22 dated 11/27/20 revealed resident could consult with audiologist. Review of speech therapy evaluation for Resident #22 dated 03/03/21 revealed the resident was hard of hearing but hearing was functional with increased volume. Review of physician visit notes for Resident #22 dated 12/01/20 and 03/15/21 revealed resident was hard of hearing. Review of the medical record for Resident #22 revealed it did not include audiology notes for resident. Observation on 05/17/21 at 1:16 P.M. revealed Resident #22 was not wearing hearing aids and was hard of hearing and required questions to be repeated multiple times due to not hearing what was being asked. Interview on 05/17/21 01:16 P.M. with Resident #22 revealed resident had a hard time hearing what was being said to her, she had hearing aids at home, and the facility had not arranged an audiology consult for her. Interview on 05/19/21 at 4:37 P.M. with Social Service Designee (SSD) #770 revealed she scheduled audiology appointments for residents based on referrals from the nurses. SSD #770 further confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 14 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 the audiologist had been in the facility on 01/26/21 but Resident #22 was not on the list to be seen and had not yet seen an audiologist during her stay. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 15 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on medical record review, review of a facility investigation, observation, resident and staff interview, and review of facility policy, the facility failed to attempt appropriate alternatives to bed rails and failed to regularly review the risks and benefits of bed rails with the resident. This affected one (#19) of seven residents reviewed for accidents. The census was 60. Findings include: Review of the medical record for Resident #19 revealed an admission date of 02/03/20 with a diagnosis of acute kidney failure. Review of the Minimum Data Set (MDS) for Resident #19 dated MDS 03/04/21 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility. Review of side rail consent signed upon admission dated 02/10/20 revealed resident used upper side rails to his bed as an enabler to assist in turning and repositioning. Further review of the form revealed the use of bed rails carried a risk of bruising and skin tears. Review of the side rail assessment for Resident #19 dated 02/03/21 revealed resident used upper half side rails as an enabler to assist with turning and repositioning in bed. Review of the care plan for Resident #19 updated 05/03/21 revealed resident had a potential for injury related to the use of side rails on bed as an enabler with a care plan goal of resident will be free of injury. Interventions included: check every shift for secure placement and function and ensure that side rails do not impede or restrict residents movement, ensure that side rails do no obstruct resident's view, monitor for decreased mobility and encourage independence, monitor for unsafe behavior, side rail assessment initial and quarterly. Review of the care plan for Resident #19 updated 05/02/21 revealed resident had a risk of impaired skin integrity related to needing assistance with bed mobility and positioning, frail small body frame, low body mass index (weight) and a history of skin tears. Review of the nurse progress for Resident #19 dated 01/11/21 revealed resident sustained two skin tears to his left forearm when he was reaching for his phone and his arm on the bed rail. Further review of the note revealed the skin tears were cleansed and steri-strips were applied to the skin tears. Review of incident investigation for Resident #19 dated 04/28/21 revealed resident sustained a skin tear to his right arm. Review of the nurse progress note for Resident #19 dated 05/14/21 revealed resident sustained a skin tear to his right hand which he sustained on 05/13/21. Observation of Resident #19 on 05/17/21 at 1:58 P.M. revealed resident had upper side rails to his bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 16 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/17/21 at 1:59 P.M. with Resident #19 confirmed he had upper side rails to his bed which he sometimes used for turning and repositioning in bed and confirmed he had sustained skin tears and bruises at times related to the side rails. Interview on 05/20/21 at 12:00 P.M. with the Director of Nursing (DON) confirmed Resident #19 had upper side rails on his bed since his admission to the facility and alternatives to side rails had not been trialed or discussed with resident. DON further confirmed the resident had sustained at least one skin tear on 01/11/21 directly related to side rails. Review of the facility policy titled Bed Safety dated 01/02/19 revealed the facility would provide a safe and appropriate sleeping environment for residents and would assess the use of bed rails quarterly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 17 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure medication was available for administration. This affected one (#18) of six residents reviewed for unnecessary medications. The facility also failed to administer insulin ordered by the physician which affected one (#22) of six residents reviewed for unnecessary medications. The census was 60. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 12/23/20 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #18 dated 12/30/20 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's.) Review of the monthly physician orders for Resident #18 for April 2021 and May 2021 revealed an order dated 12/23/20 for Tradjenta five milligram (mg) tablet once daily for treatment of diabetes. Review of the April 2021 Medication Administration Records (MAR) for Resident #18 revealed Tradjenta was not documented as administered on 04/02/21, 04/22/21, 04/23/21, and 04/30/21. Further review revealed there was a note in the MAR dated 04/22/21 indicating medication was not given due to not being available. Review of the May 2021 MAR for Resident #18 revealed Tradjenta was not given on 05/14/21 and 05/15/21 due to not being available. Review of the nurse progress notes for Resident #18 dated 04/02/21 through 05/15/21 revealed the notes contained no documentation regarding reason medication was not available and contained no documentation regarding physician notification of missed doses. Interview on 05/20/21 at 9:18 A.M. with Licensed Practical Nurse (LPN) #635 confirmed Resident #18's April 2021 and May 2021 MAR showed missed doses of Tradjenta on the following dates: 04/02/21, 04/22/21, 04/23/21, 04/30/21, 05/14/21, 05/15/21. Review of the facility policy titled Medication Administration dated 09/2018 revealed if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. Further review revealed if two consecutive doses of a vital medication are withheld or refused, the physician is notified. 2. Review of the medical record for Resident #22 revealed an admission date of 11/17/20 with a diagnosis of DM. Review of the MDS for Resident #22 dated 11/30/20 revealed resident was cognitively impaired and required extensive assistance of one staff with ADL's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 18 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan for Resident #22 dated 12/03/20 revealed resident had a diagnosis of DM and was at risk for unstable blood glucose. Interventions included monitor blood glucose as ordered, notify physician of changes in condition, monitor for signs and symptoms of hypo/hyperglycemia, administer insulin and medications as ordered. Review of the April 2021 and May 2021 monthly physician orders for Resident #22 revealed an order for Novolin insulin five units twice daily and for resident to have additional insulin given based resident's blood sugar per a sliding scale. Review of the May 2021 MAR for Resident #22 revealed Novolin insulin was not given on 05/11/21 at 11:00 A.M. due to resident's blood sugar was 104 and was not given on 05/16/21 at 11:00 A.M. due to blood sugar was 181. Review of the April and May 2021 MAR for Resident #22 revealed no insulin was given and no blood sugar was recorded for the following dates/times: 04/09/21 at 7:00 A.M., 05/07/21 at 11:15 A.M. and 5:00 P.M., 05/16/21 at 11:15 A.M. Review of the nurse progress notes for Resident #22 dated 04/09/21 through 05/16/21 revealed notes contained no documentation regarding missed doses of insulin. Interview on 05/20/21 at 12:00 P.M. with the DON confirmed the missed doses of insulin and the missed blood sugars for Resident #22. DON further confirmed there was no clinical rationale for holding Resident #22's routine insulin on 05/11/21 and 05/16/21. Review of the facility policy titled Blood Glucose Monitoring dated 05/24/18 revealed upon diagnosis of hyperglycemia, insulin coverage should be given upon the order of the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 19 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview and policy review, the facility failed to act on pharmacy recommendations in a timely manner. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 60. Findings include: Review of the medical record for Resident #18 revealed an admission date of 12/23/20 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #18 dated 12/30/20 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of monthly physician orders for May 2021 for Resident #18 revealed an order for melatonin and mirtazapine to be given routinely every night for sleeplessness. Review of the May 2021 Medication Administration Record (MAR) for Resident #18 revealed resident received melatonin and mirtazapine every night. Review of pharmacist medication regimen review (MRR) for Resident #18 dated 01/25/21 revealed pharmacist made the following recommendation to the attending physician: Resident is currently receiving the following sedative/hypnotics: melatonin and mirtazapine. Combined use of more than one sedative/hypnotic medication has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. While there may be a good rationale for the current sedative/hypnotic therapy in this resident, without documentation the use of more than one agent may be viewed as duplicate (and unnecessary) therapy. Please consider either treating this resident's insomnia with a single medication or documenting below or in your progress notes your rationale for using more than one agent. Further review of the MRR dated 01/25/21 revealed the physician had checked agreement with the pharmacist and wrote an order to discontinue melatonin. Interview on 05/20/21 09:52 A.M. with the Director of Nursing (DON) confirmed the facility had not acted upon the MRR per the pharmacist and the doctor's order to discontinue the melatonin. Review of the facility policy titled Psychotropic Medications dated 09/05/18 revealed the facility would reviews reports from the pharmacist consultant and documents in the medical record the identified irregularity has been reviewed and what, if any, action has been taken to address the irregularity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 20 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of facility policy the facility, and review of online resource from Medscape, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to consistently monitor a residents blood sugar as ordered by the physician for a resident receiving insulin. This affected one (#22) of six residents reviewed for unnecessary medications. The census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 11/17/20 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #22 dated 11/30/20 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL's.) Review of the care plan for Resident #22 dated 12/03/20 revealed resident had a diagnosis of DM and was at risk for unstable blood glucose. Interventions included monitor blood glucose as ordered, notify physician of changes in condition, monitor for signs and symptoms of hypo/hyperglycemia, administer insulin and medications as ordered. Review of the April 2021 and May 2021 monthly physician orders for Resident #22 revealed an order resident blood sugars to be checked at 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. and to notify the physician if blood sugar was below 60 or above 400. Further review of the orders revealed resident received insulin per sliding scale based on blood sugar level at 7:00 A.M., 11:15 A.M., 5:00 P.M. and 9:00 P.M. and to notify the physician if the blood sugar was below 60 or above 500. Review of the April 2021 and May 2021 Medication Administration Record (MAR) for Resident #22 revealed blood sugar was not monitored/recorded for the following dates/times: 04/02/21 at 8:00 P.M., 04/09/21 at 7:00 A.M. , 04/10/21 at 5:00 P.M., 04/12/21 at 8:00 P.M., 04/16/21 at 8:00 P.M., 04/23/21 at 8:00 P.M., 05/07/21 at 11:15 A.M.,12:00 P.M. and 4:00 P.M., 05/16/21 at 11:15 A.M. Review of the nurse progress notes for Resident #22 dated 04/02/21 through 05/16/21 revealed the notes contained no documentation regarding missed blood sugar levels as ordered by the physician. Interview on 05/20/21 at 12:00 P.M. with the Director of Nursing (DON) confirmed the missed blood sugars for Resident #22. Review of the facility policy titled Blood Glucose Monitoring dated 05/24/18 revealed upon diagnosis of hyperglycemia, insulin coverage should be given upon the order of the physician. Review of medication information per Medscape at https://reference.medscape.com/drug/lantus-toujeo-insulin-glargine-999003#5 revealed to increase frequency of glucose monitoring with changes to insulin dosage, coadministered glucose lowering medications, meal pattern, or physical activity and any changes to a patient's insulin regimen should be made under close medical supervision with increased frequency of blood glucose monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 21 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of online resource from Medscape the facility failed to ensure residents were free from unnecessary psychotropic medications when a resident received duplicate hypnotic therapy and also received antipsychotic medication without consideration for gradual dosage reduction. This affected one (#18) of six residents reviewed for unnecessary medications. The census was 60. Findings include: Review of the medical record for Resident #18 revealed a readmission date of 12/23/20 with a vascular dementia with behavioral disturbance and schizophreniform disorder. Further review of the face sheet for Resident #18 revealed resident was [AGE] years of age. Review of the Minimum Data Set (MDS) for Resident #18 dated 03/07/21 revealed resident was cognitively impaired, required extensive assistance of one to two staff with activities of daily living (ADL's), was coded negative for the presence as behaviors, was coded as receiving antipsychotic medications seven out of seven days of the assessment review period, a gradual dosage reduction (GDR) of antipsychotic medication had not been attempted and the physician had not documented a GDR as clinically contraindicated. Further review of the admitting orders for Resident #18 revealed an order dated 08/19/20 for Risperdal 0.5 milligrams (mg) every night. Review of the admitting history and physical for Resident #18 dated 08/19/20 revealed resident was ordered Risperdal 0.5 mg every night but did not include an appropriate diagnosis or clinical rationale for antipsychotic use. Review of MDS for Resident #18 revealed resident was discharged with a return not anticipated on 10/26/20. Review of MDS for Resident #18 dated 12/23/20 revealed resident was readmitted to the facility. Review of readmission orders for Resident #18 revealed an order dated 12/23/20 for Risperdal 0.5 mg every night. Review of the care plan for Resident #18 updated 03/22/21 revealed resident had a diagnosis of psychosis/schizophreniform and experienced disturbed though processes as evidenced by confusion, disorientation, delusions, hallucinations, impulsivity, inappropriate social behavior, obsessions, phobias, suspiciousness, ritual behaviors. Interventions included the following: approach: one-on-one (1:1) with social services as needed, attempt to reorient resident, consult psychiatry / psychology as needed, frequent medication reviews to maintain lowest dose requirements and highest level of functioning, identify and treat risk factors which may increase risk for psychosis such as stroke, traumatic brain injury, dementia, infections, substance abuse, chronic mental illness/schizophrenia. Review of provider notes revealed Resident #18 had not been evaluated by a psychiatrist or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 22 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 psychiatric nurse practitioner during her time at the facility for the appropriateness of Risperdal use. Level of Harm - Minimal harm or potential for actual harm Review of monthly physician orders for May 2021 for Resident #18 revealed an order for melatonin and mirtazapine to be given routinely every night for sleeplessness. Residents Affected - Few Review of the May 2021 Medication Administration Record (MAR) for Resident #18 revealed resident received melatonin and mirtazapine every night. Review of pharmacist medication regimen review (MRR) for Resident #18 dated 01/25/21 revealed pharmacist made the following recommendation to the attending physician: Resident is currently receiving the following sedative/hypnotics: melatonin and mirtazapine. Combined use of more than one sedative/hypnotic medication has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. While there may be a good rationale for the current sedative/hypnotic therapy in this resident, without documentation the use of more than one agent may be viewed as duplicate (and unnecessary) therapy. Please consider either treating this resident's insomnia with a single medication or documenting below or in your progress notes your rationale for using more than one agent. Interview on 05/20/21 09:52 A.M. with the Director of Nursing (DON) confirmed Resident #18 received duplicate hypnotic/sedative medication: melatonin and mirtazapine every night. Interview on 05/20/21 at 12:00 P.M. with the DON confirmed Resident #18 had been admitted to the facility on [DATE] with an order for the antipsychotic Risperdal 0.5 mg Resident #18 was out of the facility from 10/26/20 until readmission on [DATE] with an order for Risperdal 0.5 mg. DON further confirmed resident had not been seen by the facility's psychiatric service provider and a dosage reduction of resident's antipsychotic had not been attempted. Review of the facility policy titled Psychotropic Medications dated 09/05/18 revealed the facility would reviews reports from the pharmacist consultant and documents in the medical record the identified irregularity has been reviewed and what, if any, action has been taken to address the irregularity. Review of the facility policy titled Psychotropic Medications dated 09/05/18 revealed for residents who are admitted on psychotropic medications, the physician will review the medical record, medical history, and related factors for the appropriate diagnosis and indication for the use of the medication within 14 days of admission. If appropriate diagnosis or indication for the use of the medications cannot be determined, a gradual dose reduction will be initiated and reviewed with the resident and or resident representative. Review of online resource Medscape at https://emedicine.medscape.com/article/2008351-overview revealed Schizophreniform disorder is characterized by the presence of the symptoms of schizophrenia, but it is distinguished from that condition by its shorter duration, which is at least one month but less than six months. Review of online resource Medscape at Medscape https://reference.medscape.com/drug/perseris-risperdal-consta-risperidone-342986 revealed Risperdal is not approved for dementia-related psychosis, because of increased risk of cardiovascular or infectious related deaths and referred to black box warnings regarding the medication. The black box warnings indicated Risperdal was not approved for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 23 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm dementia-related psychosis and elderly patients with dementia-related psychosis who were treated with antipsychotic drugs were at increased risk of death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 24 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to discard expired intravenous (IV) medications. This had the potential to affect two (#23 and #163) of two residents in the facility receiving IV therapy. The census was 60. Findings include: Observation of the medication storage room on [DATE] at 10:04 A.M. with Licensed Practical Nurse (LPN) #635 revealed the following bags of expired IV medication were being stored: 10 percent (%) dextrose expired 06/2020, 02/2021, and 03/2021, 10% dextrose expired 06/2020, 15% potassium chloride in five % dextrose and 0.45 % sodium chloride expired 10/2020, ciprofloxacin expired 03/2021, levofloxacin in five % dextrose expired 09/2020 and 04/2021. Interview on [DATE] at 10:10 A.M. with LPN #635 confirmed the IV medications being stored in the medication room were expired and should be discarded. Review of the facility policy titled Storage of Medication dated [DATE] revealed outdated or discontinued medications should be immediately removed from stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 25 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations and resident and staff interview, the facility failed to offer a resident dental services. This affected one (#59) of one resident reviewed for dental care. The census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #59 revealed an admission dated 07/31/20 with a diagnosis of chronic kidney disease. Review of the care plan for Resident #59 dated 07/31/20 revealed resident exhibited dental/mouth problems related to having her own teeth. Interventions included dental consult as needed. Review of the comprehensive Minimum Data Set (MDS) for Resident #59 dated 08/07/20 revealed resident was cognitively intact and was not coded as edentulous or having dental concerns. Review of oral assessment for Resident #59 dated 08/01/20 revealed 08/01/20 was coded as none of the above for the following list of potential dental concerns: broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose), no natural teeth or tooth fragment(s) (edentulous), abnormal mouth tissue(ulcers, masses, oral lesions, including under denture or partial if one is worn), obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort, or difficulty with chewing. Further record review revealed there was no evidence of Resident #59 seeing a dentist or being offered to see the dentist. Observation of Resident #59 on 05/17/21 2:11 P.M. revealed the resident was edentulous upon admission. Resident #59 further confirmed she had an upper denture but no lower denture. Resident #59 confirmed no one from the facility had offered her the opportunity to see a dentist about obtaining a lower denture but she would like to see a dentist and get a full set of dentures because there were numerous food items she desired to eat but could not do because of no bottom denture. Interview on 05/19/21 at 4:41 P.M. with Social Service Designee SSD #770 further confirmed the facility had not made arrangements for Resident #59 to be seen by the dentist because they were not aware resident wanted bottom dentures. Interview on 05/19/21 4:43 P.M. with Registered Nurse (RN) #740 confirmed the MDS for Resident #59 dated 08/07/20 was inaccurate regarding resident's dental status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 26 of 26